Purpose: Liver lesions are common during invasive aspergillosis when the infection has disseminated from the lungs. However primary liver abscess is a very rare presentation of invasive aspergillosis. Methods: We present here a case of a large single liver localization in a non-neutropenic patient suffering from myelodysplastic syndrome. Results: A 84 year-old man with a refractory anemia with excess of blasts (13% in marrow) was admitted for high fever, hiccups and moderate pain at the right upper abdominal quadrant. He had received azacytidine for 9 months before this admission as well as deferoxamine iron chelation therapy. Physical examination did not show any other sign of infection. Laboratory findings were as follows: white blood cells 10000/μL, neutrophils 8900/μL, and grade 2 anemia. Liver function tests showed a grade 1 increase in bilirubin and transaminases and a grade 2 increase in alkaline phosphatases and gammaglutamyltransferase. C-reactive protein was increased (208 mg/L). Abdominal sonography revealed a single hepatic abscess of 8.5 cm confirmed by CT scan and MRI. Chest, sinus and brain CT scans were normal. Empiric antibiotics were administered but fever persisted. Serum Aspergillus galactomannan tests were repeatedly positive. Fine needle aspiration of the abscess provided a brownish bloody liquid. Culture yielded Aspergillus fumigatus. A 18-F-fluorodeoxyglucose PET-scan was then performed to rule out other localizations. PET scan showed a hypermetabolism in the external part of the abscess with a central necrosis and no other focus. As surgery was refused by the patient, treatment consisted of prolonged percutaneous drainage of the abscess and iv voriconazole at standard dose for one month followed by oral voriconazole. Control liver CT-scan showed decrease in size of the abscess but culture from abscess drainage remained positive while serum galactomannan test turned to negative. Voriconazole peak serum levels was high (10.5 μg/mL) as was the level in abscess fluid (8.2 μg/mL). Despite improvement of the Aspergillus lesion, patient died of progression of the myelodysplastic syndrome 61 days after admission. Conclusions: Primary liver aspergillosis is a rare disease. We speculate that portal of entry was the digestive tract although we could not identify any digestive tract lesion. Treatment combining drainage and voriconazole provided an improvement. Interestingly voriconazole levels were found to be very high in the liver abscess fluid.
Full conference title:
4th Advances Against Aspergillosis
- AAA 4th (2010)